This Doctor’s Practice Gave Me a Gutful

I had about 95 percent of my gut (small bowel or intestine) removed in 2007.

An embolus or blood clot had moved into my abdomen, causing my gut to turn gangrenous. It was the first clinical sign that my weak heart muscle was not working properly.

One of the doctors then on what I regarded as my superb team was Port Elizabeth gastroenterologist Ernst Fredericks.

About two years ago, in a bid to get to the bottom of my general crappy feeling and before my eventual diagnosis of end-stage heart failure, I arranged to see Fredericks about severe abdominal discomfort. I respected Fredericks professionally from our previous consultations and was happy to travel the round trip of 600 km for the latest examination. I’d also emailed him much information and current test results to facilitate a proper diagnosis.

Arriving at the reception desk on the day, I filled out a form with current details. When the receptionist said I needed to pay for the consultation, I confirmed I was happy to pay-and-claim back from the medical aid, as that had already been said to me when I made the appointment by telephone.

No, she said, you must ‘pay before doctor can see you’.

But, I said, how can I pay for a service I haven’t received yet?

That’s the practice policy, she said, a position she confirmed after I insisted she check with Fredericks that she was administering a policy under his authority.

I turned on my heel and walked out without seeing Fredericks. As it turned out, my problem was not in my gut but my heart, so I didn’t really need his services. (And, in saying that, I don’t mean to sound arrogant or unappreciative of his skill – it’s no light matter whether one has a heart or a gut problem.)

Many hospitals and specialists abroad insist on upfront co-payments for medical aid patients being made during pre-registration because patients simply walk out without paying after a procedure. The “show us the money first” – is evident in South Africa’s private hospital system too for patients without medical aid.

It rankles.

Dr. Vidor Friedman, a physician on the board of the American College of Emergency Physicians, says pinning patients down for pre-payment just before medical surgery is “a very murky, unclear situation… At the very least it’s poor form and goes against the intent if not the actual wording of” federal law.

Locally, University of Kwazulu-Natal law professor David McQuoid-Mason’s SA Medical Journal article is often quoted (erroneously, I believe) as justification for upfront payments.

He states though that doctors take an oath upon graduating that they will put their patients’ health first. The South African Health Professions Council rules affirm this principle. McQuoid-Mason also notes that once there is a doctor-patient relationship, a doctor may not abandon a patient on the basis that the patient is unable to pay for treatment without alternative arrangements.

But while McQuoid-Mason refers to “payment of fees before treatment”, he appears to misinterpret his own phrase about whether a doctor in South Africa has a right to demand actual hard cash payment of fees even before he or she has examined the patient.

I’m not aware that legally it is possible for a doctor to demand payment upfront. Typically healthcare professionals have a sign in the practice which states that the patient pays immediately for the consultation and then claims from the medical aid later.

Certainly, Ernst Ackermann, director of specialist medical consulting firm Healthman, says that South African doctors are not allowed to extract deposits from patients. Ackermann sent me a lengthy “Codification of Rulings” document of the Health Professionals Council of South Africa, dated 2002 which sets out the council’s formal position on fee payments.

As early as 1980 the council “resolved that it was not permissible for a practitioner to charge fees for services not yet rendered”. Medical practitioners could accept advance payment of fees by patients “for services rendered” where there was a co-payment requirement in terms of medical aid rates. But “a practitioner would be called upon to justify his or her action” if a patient endured unnecessary complications, suffering, or death because the doctor refused “to treat a patient for not paying in advance”.

“The Medical and Dental Professions Board resolved that … it was not permissible to render an account for services still to be rendered by such practitioners” although doctors could accept a guarantee of payment from a financial institution on behalf of a foreign patient.”

The HPCSA has also ruled that deposits may be required for non-personal services rendered – for example – medico-legal reports – but not for personal services, Ackermann said in a recent email response to my query.

I’ve wondered whether a doctor’s pre-payment policy is based on bad experience in a practice with patients – having consulted a doctor in the examination room – surreptitiously exit the practice to avoid settling the account. Of course, I presume that in order to avoid being seen by other staff in the practice, the patient would have to duck under the parapet of the reception counter, perhaps even crawl on the carpet, squeeze through the narrowest of door openings, before running down the passage to the car park or taxi rank.

It would also mean avoiding a follow-up appointment or even surgery that might have been scheduled. You don’t want to pitch up for a colonoscopy procedure if you’re on your doctors’ debtors’ list.

Perhaps we must begin to treat healthcare professionals just like any other service providers under the Consumer Protection Act and simply complain, complain, complain!

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